Ref: Ordinance No. 3695

Date*

TO THE CITY ENGINEER OF THE
CITY OF MICHIGAN CITY, INDIANA

I hereby make application for a PERMIT FOR PLACEMENT OF DUMPSTER ON PUBLIC RIGHTS OF WAY:*

at the following described location*:*

Street Number*

Lot No. & Block No.*

NATURE OF USE:*

Draw a sketch showing exact location*

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FURTHER DESCRIPTION: *

SIZE AND CAPACITY OF DUMPSTER; *

PLACEMENT DATE:*

REMOVAL DATE:*

CHARGE:
*

1 - 15 days: Fifteen Dollars ($15.00)

16 - 30 days: Twenty-five Dollars ($25.00)

RESPONSIBILITY: If this application for access is granted, I hereby agree to repair rights of way to pre-existing condition and maintain surface. I furthermore agree to remove all debris and leave the rights of way in a clean and orderly manner upon removal of the dumpster.
I further agree to assume all responsibility for any injury or damage to persons or property resulting directly of indirectly from the use contemplated in this application.

Current certificate of insurance provided:

Current certificate of insurance *

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